Scif E3067 Form – Fill Out and Use This PDF

Any person who makes or causes to be made any

NOTICE: California law requires employers to report within five days of knowledge every occupational injury or illness

knowingly false or fraudulent material statement

which results in lost time beyond the date of the incident OR requires medical treatment beyond first aid. If an employee

or material representation for the purpose of

subsequently dies as a result of a previously reported injury or illness, the employer must file within five days of knowledge

obtaining or denying workers' compensation

an amended report indicating death. In addition, every serious injury, illness, or death must be reported immediately by

benefits or payments is guilty of a felony.

telephone or telegraph to the nearest office of the California Division of Occupational Safety and Health.

1. FIRM NAME

DIVISION

1a. Policy Number

Please do

not use this

Column

E

2. MAILING ADDRESS (Number and Street, City, Zip)

2a. Phone Number

Case Number

M

P

3. LOCATION, if different from Mailing Address (Number, Street, City and Zip)

3a. Location Code

Ownership

L

O

Y

4. NATURE OF BUSINESS; e.g., Painting contractor, wholesale grocer, sawmill, hotel, etc.

5. STATE UNEMPLOYMENT INSURANCE

Industry

E

ACCT. NO.

R

6. TYPE OF EMPLOYER

Occupation

PRIVATE

STATE

COUNTY

CITY

SCHOOL DIST.

OTHER GOVERNMENT - SPECIFY ____________________________________

7. DATE OF INJURY / ONSET OF ILLNESS

8. TIME INJURY/ILLNESS OCCURRED

9. TIME EMPLOYEE BEGAN WORK

10. IF EMPLOYEE DIED, DATE OF DEATH

Sex

(mm/dd/yy)

________ A.M.

________ P.M.

(mm/dd/yy)

________ A.M. ________ P.M.

11. UNABLE TO WORK FOR AT LEAST ONE

12. DATE LAST WORKED (mm/dd/yy)

13. DATE RETURNED TO WORK

14. IF STILL OFF WORK, CHECK THIS

Age

FULL DAY AFTER

YES

NO

(mm/dd/yy)

BOX

DATE OF INJURY?

15. PAID FULL DAY'S WAGES FOR DATE OF

16. SALARY BEING CONTINUED?

17. DATE OF EMPLOYER'S KNOWLEDGE/

18. DATE EMPLOYEE WAS PROVIDED

Daily hours

I

INJURY OR LAST

YES

NO

YES

NO

NOTICE OF INJURY/ILLNESS (mm/dd/yy)

CLAIM FORM (mm/dd/yy)

N

DAY WORKED?

J

19. SPECIFIC INJURY/ILLNESS AND MEDICAL DIAGNOSIS if available, e.g., Second degree burns on right arm, tendonitis on left elbow, lead poisoning.

19a. BODY PART AFFECTED

Days per Week

U

R

20. LOCATION WHERE EVENT OR EXPOSURE OCCURRED (Address)

20a. ZIP

20b. COUNTY

21. ON EMPLOYER'S PREMISES?

21a. WAS ANOTHER PERSON

Y

YES

NO

RESPONSIBLE?

Weekly Hours

YES

NO

O

22. DEPARTMENT WHERE EVENT OR EXPOSURE OCCURRED, e.g., Shipping department, machine shop.

23. OTHER WORKERS INJURED OR ILL IN THIS EVENT?

R

YES

NO

Weekly Wage

24. EQUIPMENT, MATERIALS AND CHEMICALS THE EMPLOYEE WAS USING WHEN EVENT OR EXPOSURE OCCURRED, e.g., Acetylene, welding torch, farm tractor, scaffold.

I

L

25. SPECIFIC ACTIVITY THE EMPLOYEE WAS PERFORMING WHEN EVENT OR EXPOSURE OCCURRED, e.g., Welding seams of metal forms, loading boxes onto truck.

County

L

N

E

26. HOW INJURY/ILLNESS OCCURRED. DESCRIBE SEQUENCE OF EVENTS. SPECIFY OBJECT OR EXPOSURE WHICH DIRECTLY PRODUCED THE INJURY/ILLNESS,

S

e.g., Worker stepped back to inspect work and slipped on scrap material. As he fell, he brushed against fresh weld, and burned right hand. USE SEPARATE SHEET IF NECESSARY.

Nature of Injury

S

27. NAME AND ADDRESS OF PHYSICIAN (Number, Street, City, Zip)

27a. Phone Number

28. HOSPITALIZED AS AN INPATIENT OVERNIGHT?

NO

YES If yes, then, NAME AND ADDRESS OF HOSPITAL (Number,

28a. Phone Number

Part of body

Street, City, Zip)

(Number, Street, City, Zip)

29. Employee treated in Emergency Room?

YES

NO

ATTENTION: This form contains information relating to employee health and must be used in a manner that protects the confidentiality of employees to the extent possible while

the information is being used for occupational safety and health purposes. See CCR Title 8 14300.29 (b)(6)-(10) & 14300.35(b)(2)(E)2.

Source

Note: Shaded boxes indicate confidential employee information as listed in CCR Title 8 14300.35(b)(2)(E)2.*

30. EMPLOYEE NAME

31. SOCIAL SECURITY NUMBER

32. DATE OF BIRTH (mm/dd/yy)

Event

E

33. HOME ADDRESS (Number, Street, City, Zip)

33a. PHONE NUMBER

M

P

34. SEX

35. OCCUPATION (Regular job title, NO initials, abbreviations or numbers)

36. DATE OF HIRE (mm/dd/yy)

Secondary

L

MALE

FEMALE

Source

O

Y

37. EMPLOYEE USUALLY WORKS

37a. EMPLOYMENT STATUS

disabled

unemployed

37b. UNDER WHAT CLASS CODE OF YOUR

E

regular, full-time

part-time

retired

on strike

POLICY WERE WAGES ASSIGNED?

hours

days

total

Extent of Injury

E

______per day

________per week _________weekly hours

temporary

seasonal

laid-off

other

38. GROSS WAGES/SALARY

39. OTHER PAYMENTS NOT REPORTED AS WAGES/SALARY (e.g., tips, meals, overtime,

$ ___________________ per ___________________

bonuses, etc.)?

YES

NO

40. Number of employees on most recent policy inception or renewal date in effect at time of injury.

Date (mm/dd/yy)

Completed By (type or print)

Signature & Title

SCIF e3067 (REV. 9-07)

FILING OF THIS REPORT IS NOT AN ADMISSION OF LIABILITY. A CLAIM FORM MUST BE GIVEN TO THE INJURED WORKER WITHIN ONE

WORKING DAY OF YOUR KNOWLEDGE OF OCCUPATIONAL INJURY OR ILLNESS WHICH RESULTS IN LOST TIME OR MEDICAL TREATMENT.